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Request To Proceed In Forma Pauperis (Civil) CA-2 - Georgia
| Request To Proceed In Forma Pauperis (Civil) Form. This is a Georgia form and can be used in Inmate-Habeas Corpus Superior Court Statewide . |
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IN THE SUPERIOR COURT OF STATE OF GEORGIA , Plaintiff , Civil Action No. Inmate Number vs. Nature of Action: , , , Defendant(s) REQUEST TO PROCEED IN FORMA PAUPERIS I, , depose and say that I am the plaintiff in the above entitled case; that in support of my request to proceed without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress. I further swear that the responses which I have made to questions and instructions below are true. 1. List any and all aliases by which you are known: 2. Are you presently employed? G Yes G No If the answer is Yes, state the amount of your salary or wages per month, and give the name and address of your employer : If the answer is No, state the date of last employment and the amount of the salary and wages per month which you received : 3. Have you received within the past twelve months any money from any of the following sources? Business, profession or form of self-employment? G Yes G No Pensions, annuities or life insurance payments? G Yes G No Rent payments, interest or dividends? G Yes G No Gifts or inheritances? G Yes G No Any other sources? G Yes G No Administrative Office of the Courts (Revised 02-15-00) Form CA-2 <<<<<<<<<********>>>>>>>>>>>>> 2 If the answer to any of the above is Yes, describe each source of money and state the amount received from each source during the past twelve months : 4. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts) G Yes G No If the answer is Yes, state the total value of the items owned : 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No If the answer is Yes, describe the property and state its approximate value : 6. List the persons who are dependent upon you for financial support, state your relationship to those persons, and indicate how you contribute toward their support : I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and that state law provides as follows: a. A person to whom a lawful oath or affirmation has been administered commits the offense of perjury when, in a judicial proceeding, he knowingly and willfully makes a false statement material to the issue on point in question. b. A person convicted of the offense of perjury shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than ten years, or both. O.C.G.A.16-10-70. I, , do swear and affirm under penalty of law that the statements contained in this affidavit are true. I further attest that this application for in forma pauperis status is not presented to harass or to cause unnecessary delay or needless increase in the costs of litigation. Sworn to and subscribed before me this Signature of Plaintiff Date _______ day of _____________________, 20_______. ______________________________________________________ Notary Public or Other Person Authorized to Administer Oaths Please note that under O.C.G.A.42-12-5 service of an affidavit in forma pauperis, including all attachments, shall be made upon the court and all named defendants. Failure by the prisoner to comply with this code section shall result in dismissal without prejudice of the prisoners action. Administrative Office of the Courts (Revised 02-15-00) 2 Form CA-2<<<<<<<<<********>>>>>>>>>>>>> 3 THIS FORM IS TO BE COMPLETED ONLY BY AN AUTHORIZED INDIVIDUAL AT THE INSTITUTION WHERE THE INMATE PLAINTIFF IS PRESENTLY INCARCERATED, OR HIS/HER DESIGNEE. CERTIFICATION I hereby certify that the Plaintiff herein, ,has an average monthly balance for the last twelve (12) months of $ onaccount at the institution where confined. (If not confined for a full twelve (12) months, specify the number of months confined. Then compute average monthly balance on that number of months.) I further certify that Plaintiff likewise has the following securities according to the records of said institution : Authorized Officer of Institution Date NOTE: Please attach a copy of the prisoners inmate account of the last 12 months or the period of incarceration, whichever is less. Administrative Office of the Courts (Revised 02-15-00) 3 Form CA-2
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